Endoscopic Transsphenoidal Approach Research Articles

Development and validation of a prediction model for consistency of pituitary adenoma: the PiTCon score.

Pituitary adenomas (PAs) usually have a soft consistency, facilitating gross total resection. However, 5-13% of PAs with fibrous consistency are challenging to remove entirely and are accompanied by greater morbimortality. This study aims to identify the clinical and radiological characteristics that correlate with PA fibrous consistency preoperatively. A simple scoring system has been proposed to predict incidence of fibrous PAs. Consecutive interventions (226) were analyzed, all performed through an endoscopic endonasal transsphenoidal approach. Univariable and multivariable logistic regression analysis was performed. Hosmer-Lemeshow test and receiver operating characteristic (ROC) curves were assessed to evaluate the model. A point scoring system (PiTCon) was derived based on the multivariable regression model. Our study aimed to identify the clinical and radiological characteristics that correlate with fibrous tumor consistency preoperatively. The best diagnostic accuracy for predicting PA consistency consisted of five predictive factors: age, compressive symptoms, panhypopituitarism, craniocaudal extension of the PA in mm, and prior surgery. The multivariable model achieved good discrimination with an area under the curve (AUC) of the ROC curve being 0.82 and the 95% CI 0.76 to 0.88. Internal validation yielded an optimism-adjusted C-statistic of 0.80 (95% CI 0.74 to 0.86). A point scoring system (PiTCon score) was designed using the best predictive model. PA consistency can be estimated preoperatively regarding clinical and radiological characteristics. We propose a point-based scoring system (PiTCon score) that can better guide neurosurgeons in clinical decision-making and surgical risk assessment and help establish and describe patient prognosis.

Navigating the Surgical Landscape: A Comprehensive Analysis of Endoscopic vs. Microscopic Transsphenoidal Pituitary Surgery Outcomes.

Pituitary surgery, a critical intervention for various pituitary disorders, has sparked ongoing debates regarding the preference between endoscopic and microscopic transsphenoidal approaches. This systematic review delves into the outcomes associated with these techniques, taking into account the recent advancements in neurosurgery. The minimally invasive nature of endoscopy, providing improved visualization and reduced morbidity, stands in contrast to the well-established track record of the conventional microscopic method. Examining outcomes for disorders such as Cushing's disease and acromegaly, the review synthesizes evidence from Denmark, Bulgaria, and China. Noteworthy advantages of endoscopy encompass higher resection rates, shorter surgery durations, and fewer complications, endorsing its effectiveness in pituitary surgery. While emphasizing the necessity for prospective trials, the review concludes that endoscopic approaches consistently showcase favorable outcomes, influencing the ongoing discourse on the optimal surgical strategies for pituitary disorders.

Safety and efficacy of the endoscopic transsphenoidal transclival approach performed using direct cortical stimulation for pontine cavernous malformations.

Surgical treatment of brainstem cavernous malformations (CMs) is challenging. Surgery using the endoscopic transsphenoidal transclival approach (eTSTCA) is reported as a useful alternative for ventral brainstem CMs. However, CMs located in the ventral midline of the brainstem are rare, and only a small number of case reports on these CMs treated with the eTSTCA exist. The efficacy and safety of the eTSTCA have not yet been fully examined. A retrospective analysis was performed for 5 consecutive patients who underwent surgery via the eTSTCA for treating ventral pontine CMs. The average maximum CM diameter was 26.0 mm (18-38 mm). All patients underwent MR-diffusion tensor imaging, which confirmed that the corticospinal tract (CST) deviated posteriorly or laterally to the CM. Direct brainstem cortical stimulation was performed to localize the CST before making the cortical incision. After the excision of the CM, the cavity was filled with artificial CSF to make an aqueous surgical field (wet-field technique) for observing the tumor cavity and confirming complete hemostasis and resection. Total removal was achieved in all patients. The preoperative modified Rankin Scale score was 3 in 3 patients and 4 in 2 patients, whereas it was 1 in 2 patients and 0 in 3 patients 3 months after surgery. Postoperative CSF leakage was observed in 1 patient, and transient abducens nerve palsy was observed in 1 patient. No other intra- or postoperative complications were observed. MR-diffusion tensor imaging and direct brainstem cortical stimulation were useful to ascertain the proximity of the CST to the CM. The endoscope provides a clear view even underwater, and it was safe and effective to observe the entire CM cavity and confirm complete hemostasis without additional retraction of the brainstem parenchyma, including the CST. The eTSTCA provides a direct access point to the lesion and may be a safer alternative treatment for patients whose CST deviates laterally or posteriorly to the CM.

Unusual Presentations of Sellar and Suprasellar Space Occupying Lesion: Our Institutional Experience

AbstractA pituitary abscess (PA) is a rare intracranial lesion. It is a critical disorder caused by an infectious process where purulent material accumulates inside the sella turcica. It occurs either as a primary disease or because of an infection and is associated with poor prognosis. In this article, we share our experience with PA. At our institution, we operated on five cases of pituitary abscess since 2016. All the cases presented with bitemporal hemianopia and headache. None of them had fever. Pituitary hormones were normal except in two patients with a previous history of hypothyroidism. Magnetic resonance imaging (MRI) of the brain showed pituitary macroadenoma. They underwent the endoscopic transnasal transsphenoidal approach. Postoperatively their vision has improved. Endocrine functions were normal in all the patients following surgery. Culture sensitivity was sterile in all the patients. Diagnosis of pituitary abscess is highly difficult before surgery. Hence, the diagnosis should be considered when a patient presents with fever, headache, and signs of pituitary dysfunction and meningeal inflammation. Surgical and medical management leads to a lower mortality rate and a higher probability of hormone function recovery.

P-62 Silent Corticotroph Adenoma or Cyclic Cushing's Syndrome?

Abstract Introduction Silent corticotroph adenomas (pituitary neuroendocrine tumours (PitNET)) are a rare subset of nonfunctioning adenomas. The higher aggressiveness in terms of invasion and recurrence make these tumors dangerous and close follow-up in experienced centers is recommended. Clinical Case A 21-year-old obeseo (Body Mass Index:31.71) male patient unable to lose weight and complaining of headaches was referred to the Department of Neurosurgery for a pituitary macroadenoma. He had previously used liraglutide treatment Many purple striae were also seen on the body of the patient, who stated that his wounds did not heal easily. Visual acuity and visual field were normal. There was no neurodeficiency. Endocrinological evaluation revealed that the tumor was nonfunctioning (Table 1). Magnetic resonance imaging of the pituitary gland showed a mass lesion in the right side of the pituitary gland extending to the suprasellar and parasellar area (Knosp grade II) (Fig.1). The tumor with soft consistency was totally removed by endoscopic binostril transsphenoidal approach. The postoperative cortisol was 11.53 µg/dl (6.02-18.4) and free T4 was 1.32 ng/dL (0.93-1.7). The patient had a transient diabetes insipidus in the postoperative course, and he was discharged on the 4th day after surgery. Pathological examination revealed a pituitary adenoma immunostaining diffusely with ACTH, other hormones were unexpressed. Ki-67 was %2. Histological invasion of the dura was noted. Although the patient was clinically overweight and had purple striae suggestive of Cushing's syndrome (CS), his cortisol and ACTH levels were normal and suppressible with 1 mg dexamethasone suppression test. However, his tumour tissue showed diffuse ACTH expression, which led to the diagnosis of a silent ACTH adenoma. Since the clinical findings were not completely silent, could we assume that he suffered from cyclic CS? Cyclic (intermittent or periodic) CS is a condition characterised by alternating periods of transiently elevated cortisol levels followed by normal to reduced levels. The diagnosis of cyclic CS requires the presence of at least three confirmed episodes of elevated cortisol levels interspersed with two periods of normal cortisol levels. As we know, the cortisol secretion cycle is unpredictable and laboratory tests during the normal cortisol secretion period of the cyclic CS often show negative results as in our patient. Conclusion Postoperative follow-up of a silent corticotroph PitNET and cyclic CS patient, both of whom require close and life-long monitoring.Figure 1.Magnetic resonance imaging of the pituitary gland; coronal sections T1- weighted (a), T2-weighted (b), sagittal (c), and coronal (d) sections with T1 contrast enhancement. The mass lesion on the right side of the pituitary gland extending superiorly to the right internal carotid artery contains a hemorrhagic fluid component with heterogeneous contrast enhancement, is 16*12*9 mm in size, and corresponds to a hemorrhagic pituitary macroadenoma. Table 1.Hormonal values at presentationACTH, adrenocorticotropic hormone; DST, dexamethasone suppression test; fT4, free thyroxine; IGF-1, insulin-like growth factor 1; PRL, prolactin; TSH, thyroid-stimulating hormone.

Predictive value of suprasellar extension for intracranial infection after endoscopic transsphenoidal pituitary adenoma resection

ObjectiveTo investigate the relationship between suprasellar extension (SSE) and intracranial infection after endoscopic endonasal transsphenoidal approach (EETA) for pituitary adenoma resection.MethodsWe retrospectively analyzed 94 patients with suprasellar extended pituitary adenoma admitted to the Department of Neurosurgery of the Affiliated Hospital of Guilin Medical College from January 2018 to December 2021. We measured the preoperative magnetic resonance sagittal SSE and collected clinical data and divided the patients into groups according to the presence of postoperative intracranial infection. The critical value for the SSE was calculated by using a working characteristic curve for the subjects. The risk factors for intracranial infection after EETA resection of pituitary adenomas were analyzed by multivariate regression analysis.ResultsAmong the 94 patients, 12 cases (12.8%) were placed in the infection group and 82 cases (87.2%) in the non-infection group. The cut-off value for the SSE in the sagittal position was 15.6 mm, the sensitivity was 75%, the specificity was 87.8%, and the area under the curve (AUC) was 0.801. The coronary cut-off value for the SSE was 15.8 mm, the sensitivity was 66.7%, the specificity was 79.3%, and the AUC was 0.787. The SSE values in the sagittal and coronal positions were correlated with postoperative intracranial infection (P < 0.05). After univariate analysis, those with significant differences were included in the multivariate regression analysis. It was concluded that the extension distance of the tumor above the sella in the sagittal position was ≥ 15.6 mm, the tumor texture was hard, and the postoperative cerebrospinal fluid leakage were the independent risk factors for intracranial infection after EETA resection of suprasellar extended pituitary tumors (P < 0.05).ConclusionsThe value of SSE on sagittal MRI can predict intracranial infection in patients with suprasellar extended pituitary adenoma after endoscopic endonasal transsphenoidal resection. This finding recommends neurosurgeons pay more attention to the imaging characteristics of pituitary adenomas and select appropriate treatment plans in combination with the intraoperative conditions to reduce the incidence of intracranial infection.

Effectiveness of endoscopic endonasal surgery for pituitary apoplexy: A comprehensive evaluation of presentation and clinical outcomes from a tertiary care center

BackgroundThe management of pituitary apoplexy (PA) is under debate. Therefore, we studied the clinical manifestations and neuroendocrine outcomes of PA after surgical management, as well as the efficacy and safety of the endoscopic endonasal transsphenoidal approach (EETA). MethodsThis retrospective study was conducted between January 2013 and May 2021, and included 62 cases of pituitary adenoma apoplexy that were managed with EETA. ResultsData from 62 patients were analyzed with a mean age of 50.7 ± 10.9 years, 90.3 % of whom were female. On admission, most patients presented with abrupt onset severe headache and vomiting, associated with endocrine dysfunction in 43.5 % and deteriorated visual acuity in 92 %. Third nerve palsy was the most noted ocular nerve palsy. After using EETA, the adenoma was resected totally, subtotally, and partially in 59.7 %, 29 %, and 11.3 % of the cases, respectively. Postoperative improvement in visual acuity was achieved in 90.3 % of patients, unchanged in 6.5 % with vision defects, and deteriorated in 3.2 %. Endocrine dysfunction improved to 19.3 % after being 43.5 %. Six patients (9.6 %) experienced transient diabetes insipidus (DI) that responded completely to desmopressin therapy for a time, and three cases were complicated with CSF leakage after the operation, but it resolved completely. No intracranial infection, carotid artery injury, or death occurred. ConclusionDespite the availability of alternative treatment options, the surgical intervention by EETA remains the most effective and reliable method for managing patients with PA who present with sudden visual or endocrine symptoms. EETA has been shown to result in significant improvements in both visual and endocrine function, with an acceptable complication rate that can be managed effectively in many cases. As such, EETA continues to represent the cornerstone in the management of PA and should be considered the first-line treatment option for amenable patients.

내시경적 경접형동 접근법에서의 중비갑개 부분 절제가 후각 기능에 미치는 영향

Background: There are controversies on whether endoscopic transsphenoidal approach (TSA) affects postoperative olfaction. This study aimed to compare olfactory function in regard of partial resection status of middle turbinate (MT) and analyze the amount of resection in images.&#x0D; Materials and Methods: This study retrospectively reviewed 46 patients who had undergone endoscopic TSA due to pituitary adenoma or Rathke’s cleft cyst from 2015 to 2019. MT preserva-tion (MTP) group was defined as the group of patients whose MTs were preserved. MT resection (MTR) group was defined as the group of patients whose MTs were partially resected unilaterally or bilaterally. Olfactory function was compared with pre- and postoperative 3-month Korean version of sniffing sticks test-II which was composed of threshold, discrimination, identification (TDI) scores each making 16 with correct answers. Pre- and postoperative images including paranasal computed tomography and sellar magnetic resonance imaging were analyzed using Picture Archiving and Communication System.&#x0D; Results: There were 41 pituitary adenomas and 5 Rathke’s cleft cysts. Male patients were 39.1% (n = 18) and mean age was 42.6. About 1/3 (31%) of MT was resected in MTR group (n = 13), which had the effect of increasing the cross-sectional area of the nasal cavity by 19%. Post-septectomy area was 6% of total septum. Preoperative TDI score was 27.34 and postoperative TDI score was 25.42. There were no significant differences of olfactory score in total, MTR and MTP groups 3 months after endoscopic TSA.&#x0D; Conclusions: Resection of lower third of MT may produce low morbidity in respect of olfactory function after endoscopic TSA.

Anterior-posterior diameter is a key driver of resectability and complications for pituitary adenomas with suprasellar extension in endoscopic transsphenoidal surgery.

As endoscopic transsphenoidal approaches are more routinely selected for progressively larger pituitary adenomas with parasellar extension, understanding potential anatomical factors that limit resection and contribute to complications is becoming increasingly important for tailoring a surgical approach. This study aimed to reevaluate existing predictive tools for resectability in pituitary adenomas specifically with suprasellar extension, and furthermore identify any additional measurable features that may be more useful in preoperative planning. A single-center retrospective chart review of adult patients who underwent endoscopic transsphenoidal surgery for pituitary adenomas with suprasellar extension from 2015 to 2020 was performed. Preoperative MRIs were systematically assessed to assign a Knosp classification, a Zurich Pituitary Score (ZPS), and for dimensional measurements of the suprasellar aspect of the lesions. Univariate comparisons and multivariate regression models were employed to assess the influence of these factors on extent of resection and postoperative complications. Of the 96 patients with suprasellar pituitary adenomas who underwent endoscopic transsphenoidal surgery, 74 patients (77%) had a gross total resection (GTR). Neither Knosp grade nor ZPS score, even when dichotomized, demonstrated an association with GTR (Knosp 3A-4 versus Knosp 0-2, p = 0.069; ZPS III-IV versus ZPS I-II, p = 0.079). Multivariate regression analysis identified suprasellar anterior-posterior tumor diameter (SSAP) as the only significant predictor of extent of resection in this cohort (OR 0.951, 95% CI 0.905-1.000, p = 0.048*). A higher SSAP also had the strongest association with intraoperative CSF leaks (p = 0.0012*) and an increased overall rate of postoperative complications (p = 0.002*). Further analysis of the regression model for GTR suggested an optimal cut point value for SSAP of 23.7mm, above which predictability for failing to achieve GTR carried a sensitivity of 89% and a specificity of 41%. This study is unique in its examination of endoscopic transsphenoidal surgical outcomes for pituitary adenomas with suprasellar extension. Our findings suggest that previously established grading systems based on lateral extension into the cavernous sinus lose their predictive value in lesions with suprasellar extension and, more specifically, with increasing suprasellar anterior-posterior diameter.

An Endoscopic Endonasal Attempt at Pediatric Meningoencephalocele Repair.

Meningoencephalocele is an abnormal skull base protrusion of fluid, brain tissue, and meninges that can lead to nasal obstruction, meningitis, and Cerebrospinal Fluid (CSF) rhinorrhea. This condition can be managed operatively through an open craniotomy or a less invasive endoscopic approach. Here, we report a case of an 18-month-old female who presented with a meningoencephalocele that was part of the Sakoda complex, a rare neurosurgical phenomenon consisting of meningoencephalocele, agenesis of the corpus callosum, and cleft lip/palate. The patient was initially treated with the endoscopic transsphenoidal approach with subsequent open craniotomy.

Leukocyte- and platelet-rich fibrin in endoscopic endonasal skull base reconstruction: study protocol for a multicenter prospective, parallel-group, single-blinded randomized controlled non-inferiority trial

BackgroundRecent advances in endoscopic endonasal transsphenoidal approaches (EETA) for skull base lesions have resulted in a significant increase in extent and complexity of skull base defects, demanding more elaborate and novel reconstruction techniques to prevent cerebrospinal fluid (CSF) leakage and to improve healing. Currently, commercially available fibrin sealants are often used to reinforce the skull base reconstruction. However, problems have been reported regarding hypersensitivity reactions, efficacy, and costs. This trial aims to investigate autologous leukocyte- and platelet-rich fibrin (L-PRF) membranes as an alternative for commercially available fibrin glues in EETA-related skull base reconstruction reinforcement.Methods/designThis multicenter, prospective randomized controlled trial aims to demonstrate non-inferiority of L-PRF membranes compared to commercially available fibrin sealants in EETA cases (1) without intra-operative CSF-leak as dural or sellar floor closure reinforcement and (2) in EETA cases with intra-operative CSF-leak (or very large defects) in which a classic multilayer reconstruction has been made, as an additional sealing. The trial includes patients undergoing EETA in three different centers in Belgium. Patients are randomized in a 1:1 fashion comparing L-PRF with commercially available fibrin sealants. The primary endpoint is postoperative CSF leakage. Secondary endpoints are identification of risk factors for reconstruction failure, assessment of rhinological symptoms, and interference with postoperative imaging. Additionally, a cost-effectiveness analysis is performed.DiscussionWith this trial, we will evaluate the safety and efficacy of L-PRF compared to commercially available fibrin sealants.Trial registrationClinicalTrials.gov NCT03910374. Registered on 10 April 2019.

Application of a Novel Versatile Mini Posterior Nasoseptal Graft in Endoscopic Transsphenoidal Pituitary Adenoma Surgery.

Skull base reconstruction is a key technique in patients undergoing endoscopic transnasal skull base surgery. Although a pedicled nasoseptal flap (PNSF) is often used to repair large skull base defects with high-flow cerebrospinal fluid leakage, bone exposure of the donor site of the PNSF can result in long-term crusting. To design a novel and versatile mini posterior nasoseptal graft for the reconstruction of defects in the sellar floor or PNSF or pedicled nasoseptal rescue flap (PNSRF) donor site in patients undergoing pituitary adenoma surgery. Patients who underwent pituitary adenoma removal through an endoscopic endonasal approach and repair of a sellar defect or PNSF/PNSRF donor site using the mini posterior nasoseptal graft technique from January 2019 to January 2020 were retrospectively evaluated. Pituitary adenomas were removed using a binostril 4-hand technique through a transnasal transsphenoidal transsellar approach or an expanded transsellar approach. Mini posterior nasoseptal grafts were successfully used in 70 patients who underwent pituitary adenoma removal through an endoscopic transsphenoidal sellar approach. Mini posterior nasoseptal grafts repaired sellar defects in 40 patients and donor site defects of the contralateral PNSF/PNSRF in 30 patients. None of these patients experienced cerebrospinal fluid leakage or major complications. A mini posterior nasoseptal graft is a safe and effective technique for repairing sellar defects after endoscopic transnasal pituitary adenoma surgery. This technique can also be used to repair defects in PNSF/PNSRF donor sites.

Quantitative Evaluations of Vestibular Function in Patients With Petrous Apex Cholesterol Granulomas Treated With an Endoscopic Transsphenoidal Approach: A Report of Two Cases.

We report two cases of petrous apex cholesterol granuloma (PACG) treated with an endoscopic transsphenoidal approach. Vestibular functions of the two patients were evaluated quantitatively by video Head Impulse Test (vHIT) and/or vestibular evoked myogenic potentials (VEMPs). Two patients with PACG who experienced episodes of dizziness are presented. An endoscopic transsphenoidal approach to PACG. The preoperative and postoperative vestibular functions as evaluated by vHIT and VEMP. Two cases of PACG were treated by a transsphenoidal approach. The internal auditory canal was compressed by the PACG in both cases. The patients both experienced episodes of dizziness before surgery and preoperative vestibular testing including vHIT and VEMP indicated dysfunction of vestibular nerves. After surgery, their symptoms were completely resolved, and the vestibular testing results were improved. This article is noteworthy for being the first to publish quantitative vestibular function testing for patients with PACG with vestibular dysfunction. PACG may show various symptoms, with dizziness being one of the most common symptoms. In cases in which the internal auditory canal is compressed by the PACG, vestibular functions should be evaluated by vHIT and VEMP. In the present cases, dizziness was found to be resolved by surgery to release the compression on internal auditory canal. Based on the present cases, the transsphenoidal approach is considered to be both safe and effective.

Endoscopic endonasal approach for MRI–Negative Cushing’s microadenoma

A 54-year-old male with a history of diabetes mellitus type 2 for 12 years and hypertension was seen in the clinic due to poorly controlled diabetes. Inferior petrosal sinus sampling (IPSS) confirmed Cushing’s disease with primary adrenocorticotropic hormone (ACTH)–secreting pituitary adenoma on the right. However, 3T and subsequent 7T MRI showed no visible tumor. An endoscopic transsphenoidal approach was selected to explore the pituitary gland and resect the presumed microadenoma. Tumor was identified in the lateral recess along the right medial cavernous sinus wall and gross-total resection (GTR) was performed. The normal pituitary gland was preserved, and the patient went into remission. The video can be found here: https://stream.cadmore.media/r10.3171/2023.4.FOCVID2324

Endoscopic Orientation of Juxta-pituitary Carotid in Transsphenoidal Approaches: Critical Considerations for Clinical Applications.

Introduction In sphenoid sinuses with ill-defined carotid bony landmarks, accidental injury of the internal carotid artery (ICA) remains one of the most challenging complications, which is particularly reported in the endoscopic endonasal transsphenoidal approaches (EETAs). Objectives To describe an anatomical model for the endoscopic orientation of the juxta-pituitary segment of the ICA in relation to the lateral opticocarotid recess (OCR) as a nearby bony landmark. Methods Dissection was performed progressively, simulating the EETA, in twenty fresh adult cadavers. After reducing the posterior and lateral walls of the sphenoid sinuses, various measurements were taken from both lateral OCRs to "contact points" on the juxta-pituitary segment of the ICA and lateral margins of the pituitary gland. Results The current results have enabled us to divide the region between the lateral OCRs into 3 compartments: 2 lateral parasellar compartments contain juxta-pituitary segments of the ICA with a mean width of 8 mm and a narrow range from 7 mm to 10 mm; and a central intercarotid sellar compartment represents the safe region for bone drilling, showing widely variable widths ranging from 9 mm to 20mm. In all specimens, the variation in the width of the intercarotid compartment correlated with the distance between both lateral OCRs. Conclusion The present study improves surgeon awareness of the variations in the course of the ICA through the EETA along sphenoid sinuses with ill-defined bony landmarks. An appreciation of the measurements taken in the present study can help in operative training, and can also provide a base for future studies to confirm ICA courses associated with a higher risk of injury.

Improvements in the Endoscopic Transsphenoidal Resection of Craniopharyngiomas: A Global Learning Curve

Surgical management of craniopharyngiomas is nuanced and has varied in terms of the selected approach and aggressiveness of resection over time. In the past several decades, the endoscopic transsphenoidal approach has become commonly used for craniopharyngioma resection. There is a well characterized institutional 'learning curve' regarding endoscopic transsphenoidal approaches for craniopharyngiomas at specialized centers, however the broader global learning curve remains to be characterized. Clinical outcome data following endoscopic transsphenoidal craniopharyngioma resection were obtained from a previously published meta-analysis, including data published during or after the year 1990. Additionally, the year of publication, the country where procedures were performed, and the human development index (HDI) of the country at time of publication were abstracted. Meta-regressional analyses were used to determine the significance of year and HDI as a covariate of the logit event rate of clinical outcomes. Statistical analyses were performed using the Comprehensive Meta-Analysis with a priori significance set as P<0.05. A total of 100 studies (8,230 patients) were examined, representing data from 19 countries. There was a significant increase in the achieved gross total resection rate (P=0.0002) and a decrease in the achieved partial resection rate (P<0.0001) across the time studied. Additionally, the rate of visual worsening (P=0.025), postoperative cerebrospinal fluid leaks (P=0.007), and development of meningitis (P=0.032) decreased across time. This work suggests the existence of a global learning curve when examining clinical outcomes following endoscopic transsphenoidal craniopharyngioma resection. Globally, these findings highlight a general improvement in clinical outcomes across time.

Endoscopic transsphenoidal surgery and Haddad nasoseptal flap of Rathke’s cleft cysts

Introduction: Rathke’s cleft cysts (RCC) grow formed from remnants of the embryologic Rathke’s pouch and are often found incidentally in the sellar or suprasellar region. These lesions are usually asymptomatic in most people. However, as the cyst progressively enlarges, they may develop symptoms typical of RCC, including headache, vision loss, and endocrine dysfunction. The diagnosis procedure involves an MRI scan of the pituitary gland. The endoscopic transsphenoidal approach has become the most common surgical approach to treat RCC. In the last 15 years, endonasal endoscopy has been widely used in the surgical management of these lesions. Case report: A 58-year-old Asian woman was reported mainly with a complaint of headache that had increased over the last two months, occasional nausea and vomiting, and blurred vision experienced for 1 month.

Morphometry and Intracranial Relations of the Sphenoid Sinus in Context to Endoscopic Transnasal Transsphenoidal Surgery.

Introduction Due to the variable degree of pneumatization, the shape and size of the sphenoid sinus are irregular. An endoscopic intranasal transsphenoidal approach is made in sphenoid sinus pathologies, sphenoid sinusitis, and sellar and parasellar diseases. A diagnostic approach to the sphenoid sinus is also done to get a better MRI scan of the pituitary. The present study aims to describe the variant types of sphenoid sinus, morphometry, anatomy, and relations of sphenoid sinus, which will be helpful to surgeons during an endoscopic approach to the sphenoid sinus. Materials and methods We studied 76 cadaveric sphenoid sinuses that were exposed by taking a sagittal section of 38 formalin-fixed cadaveric heads. After examining the inter-sphenoidal septum, it was removed to observe the inside aspect of the sphenoid sinus. Different dimensions of the sinus were noted down. The bulges inside the sinus due to neurovascular structures in relation to the sinus were observed. Results The most prominent type found was the sellar in 68.4% of cases preceded by the postsellar in 23.7% of cases. Presellar type of pneumatization was seen only in 7.9% of cases and the conchal type was absent.Intersphenoid septum was seen in 92,1% of cases, out of which 11.4% of septums were deficient on the posterior aspect. An internal carotid artery bulge in the sphenoid sinus was seen in 46% of cases. In 27.6% and 19.7% of sphenoid sinuses, bulging of the optic and vidian nerves, respectively, were seen. Some of these structures were dehiscent in the sphenoid sinus. Conclusions To get more space in the sphenoid sinus, the septa in the sinus are removed by surgeons, which may damage the walls of the sphenoid sinus. Knowledge of the relations of neurovascular structures with the sphenoid sinus will be helpful to surgeons during the transsphenoidal endoscopic approach to avoid any injury to these structures.

Outcomes of Endoscopic Transsphenoidal Approach for More Aggressive Pediatric Pituitary Adenomas: Early- and Late-Term Results from a Single Center Experience

Pediatric pituitary adenomas are rare lesions and account for approximately 3% of all supratentorial tumors in children.There is a paucity of reports on endoscopic transsphenoidal surgery in children. The aim of this study was to assess the early/late outcomes of endoscopic pediatric pituitary adenoma surgery at a high-volume tertiary center, as well as to characterize the factors associated with aggressive growth, including the histopathological features. Between August 1997-June 2022, a total of 3256 patients underwent endoscopic transsphenoidal surgery for pituitary adenoma at the Department of Neurosurgery and Pituitary Research Center of the Kocaeli University School of Medicine. Of these, 70(2.1%) pediatric patients (25 male,45 female)(age ≤18 years) with a pathological diagnosis of pituitary adenoma were retrospectively reviewed. The mean age of patients was 15.5±2.3 years.Among the hormone-secreting adenomas, 19(34.5%) were adrenocorticotrophic hormone (ACTH)-secreting, 13(23.6%) were growth hormone (GH)-secreting, 19(34.5%) were prolactin (PRL)-secreting, and 4(7.2%) were both GH- and PRL-secreting.Gross total resection was achieved in 93.3% of nonfunctional tumors.The early/late surgical remission rates for hormone-secreting adenomas were 61.5%/46.1%(mean follow-up:63.7±49.3 months) for acromegaly, 78.9%/68.4%(47.8±51.0 months) for Cushing's disease, 57.8%/31.5%(72.2±59.5 months) for prolactinoma, and 25%/25%(35.2±31.4 months) for GH+PRL-secreting adenomas.Five sparsely-granulated corticotroph tumors, 5 sparsely-granulated somatotroph tumors, and 11 densely-granulated lactotroph tumors were classified as aggressive histopathological subtypes. The unique characteristics of the pediatric population and the aggressiveness of the disease in this population pose considerable therapeutic challenges. To increase treatment success, current adjuvant therapies that are appropriate for the morphological and biological characteristics of the tumor are required in addition to surgical treatment.

A silent corticotroph adenoma: making the case for a pars intermedia origin. Illustrative case.

Silent corticotroph adenomas (SCAs) are the only pituitary adenomas thought to originate from the pars intermedia. This case report presents the rare finding of a multimicrocystic corticotroph macroadenoma displacing the anterior and posterior lobes of the pituitary gland on magnetic resonance imaging (MRI). This finding supports the hypothesis that silent corticotroph adenomas may originate from the pars intermedia and should be considered in the differential for tumors arising from this location. A 55-year-old man presented with an episode of confusion and blurred vision. MRI demonstrated separation of the anterior and posterior glands by a solid-cystic lesion located within the pars intermedia that superiorly displaced the optic chiasm. Endocrinologic evaluation was unremarkable. The differential diagnosis included pituitary adenoma, Rathke cleft cyst, and craniopharyngioma. The tumor was confirmed to be an SCA on pathology and was completely removed through the endoscopic endonasal transsphenoidal approach. The case highlights the importance of preoperative screening for subclinical hypercortisolism for tumors arising from this location. Knowledge of a patient's preoperative functional status is critical and dictates their postoperative biochemical assessment to determine remission. The case also illustrates surgical strategies for resecting pars intermedia lesions without injuring the gland.